Basic Information
Provider Information | |||||||||
NPI: | 1932844636 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCNELLIS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | CARA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GIBSON | ||||||||
OtherFirstName: | MICHAEL | ||||||||
OtherMiddleName: | CARA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1832 | ||||||||
Address2: |   | ||||||||
City: | PITTSBURG | ||||||||
State: | KS | ||||||||
PostalCode: | 667621832 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6202405668 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1624 S NATIONAL AVE | ||||||||
Address2: |   | ||||||||
City: | FORT SCOTT | ||||||||
State: | KS | ||||||||
PostalCode: | 667012645 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6206449048 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/28/2022 | ||||||||
LastUpdateDate: | 09/09/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/09/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 81373 | KS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.